1. IRRITABLE BOWEL SYNDROME Barbara L. Slee, M.D.

2. IBS Epidemiology and pathophysiology Symptoms and signs of Dx Appropriate Work-up Treatment

3. Definition of IBS Benign GI disorder Chronic abdominal pain Altered bowel habits Absence of organic causes

4. Epidemiology Incidence: 10-15% pop. Most common GI disorder 2:1 female/male Younger patients 2 nd highest cause of missing work $2-8 billion

5. Pathophysiology Altered GI motility Visceral afferent hypersensitivity Psychosocial dysfunction

7. Clinical Presentation?

8. Clinical Presentation Chronic episodic abdominal pain Cramping Pain relieved by defecation Looser, more frequent stools Diarrhea, constipation, or alternating Mucous in stool

9. Clinical Presentation Bloating, gas Dyspepsia, Nausea Atypical chest pain Symptoms worse during stressful time Normal Exam

10. Diagnosis Criteria Manning Rome I Rome II –12 or more wks of abd pain –+2 or more of following Relieved by defecation Change in frequency Change in form

11. Alarm symptoms or Red Flags?

12. Alarm Symptoms (Red Flags) Anemia Family history colon CA or IBD Fever Nocturnal symptoms

13. Red Flags (con’t) Bleeding >10 lb wt loss Recent Antibiotic Severe chronic diarrhea > age 50

14. Work-up for IBS 27 y/o female pt Intermittent, crampy abdominal pain Stool urgency, relief of pain with BM No alarm findings What studies?

15. REC. W/U for IBS Pretest probability of organic disease <1% Same in healthy controls

16. Diagnostic Studies in IBS: CBC, Chem 14 Stool O&P – if diarrhea, endemic infection +/- TSH – severe diarrhea +/- hemoccult +/- ESR (younger pt) Colonoscopy – age >50

17. Screen for Celiac Dz Incidence in IBS = 5% Healthy controls <1% If diarrhea predominant sx - –Antigliadin Ab, antimysial Ab –Upper endoscopy with Biopsy if suspicious and Abs negative

18. Treatment How do you want to Treat your patient?

19. Treatment: Doctor –patient relationship Education Reassurance Chronic benign nature

20. Dietary – Food exclusions Lactose Fructose Foods that increase flatulence Caffeine Any food they find increases their sxs

21. Medication: Adjunct only Avoid chronic use Use based on predominant symptoms Lack of convincing evidence of efficacy

22. Pain Sx: Anti-spasmotics –Bentyl –Hyoscymine – Levsin, Symax TCA’s –Low dose –Decrease visceral sensitivity, motility, secretions

23. Diarrhea predominant sx: Loperimide (lomotil) prn Cholestyramine (questran) Ondansetron (Zofran) 5HT3 antagonist Alosetron (Lotronex) 5HT3 antagonist

24. Constipation predominant sx: Fiber 25 g/day Tegaserod (Zelnorm) HT4 Agonist –Studies valid for efficacy in women only

25. Cost of Medication Zelnorm 2mg or 4 mg$100/mo Lotronex 1 mg 252/mo Zofran 8 mg 1277/mo

26. Pychotherapy: Symptoms unresponsive Impair health related quality of life Co-morbid psychological diagnosis History of Physical or sexual abuse Learned patterns of illness behavior

27. Psychotherapy Mental health professional part of Treatment Team No one Psych therapy modality superior

28. Summary Etiology is unclear IBS pathophysiology is multifactorial Diagnosed by H&P Requires minimal lab evaluation in absence of Alarm symptoms

29. Summary Treatment is first reassurance and non- pharmacological measures Pharmacotherapy is used when needed and for brief periods only

30. Handouts Text of lecture Criteria for Diagnosis of IBS Treatment Strategy Chart for IBS from NEJM, Irritable Bowel Syndrome: Review Article Nov. 27, 2003 Cover Article from AFP Nov. 15, 2002, Management of Irritable Bowel Syndrome by Anthony Viera and Steve Hoag

31. References 1. Evidence-Based Position Statement on the Management of Irritable Bowel Syndrome in North America; ACG, American Journal of Gastroenterology, Vol. 97 No. 11 Suppl., 2002 2. Systematic Review on the Management of Irritable Bowel Syndrome in North America; L.J. Brandt, M.D., chairman, David Bjorkman, M.D., M. Brian Fennerty, M.D. et. al, The American Journal of Gastroenterology, Vol. 97, No.11, Suppl., 2002

32. References 3. Schoenfeld, MD, Philip, Efficacy of Current Drug Therapies in Irritable Bowel Syndrome: What Works and Does Not Work. Gastroenterology Clinics of North America, 34 (2005) 319-335 4. Anthony Viera, Steve Hoag, Lt. MC. Management of Irritable Bowel Syndrome, AFP Nov. 15, 2002 5. AGA Guideline: Irritable Bowel Syndrome, Gastroenterology 2002; 123:2105

33. References 6. Anddrew B. chun, M.D., Steven Desautels, MD, Arnold Wald, MD. Clinical Manifestations and diagnosis of Irritable Bowel Syndrome, UpToDate. Online 13.2 7. Sanders DS, Carter MJ, et al. Irritablae Bowel Syndrome Was significantly Associated with Celiac Disease: Update in Gastroenterology and Hepatology. Annals of Internal Medicine, Sept. 7, 2004.

34. Other Interesting Reading: 1. The Role of Food Intolerance in Irritable Bowel Syndrome, Raichard Lea, Peter Whorwell, MD. Gastroenterology Clinics of North America 34 (2005) 247-255 2. Probiotics: An Ideal Anti-inflammatory Treatment for IBS? Editorial, Gastroenterology Vol. 128 No. 3